MEDICARE: DR. TARA KUKNYO ORECH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D13817	MN

General Provider Information

NPI Number	:	1508395146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA KUKNYO ORECH DDS

Provider Business Mailing Address
First Line	:	1625 37TH AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-4043
Country	:	US
Telephone Number	:	630-945-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 39TH AVE NE STE 225
Second Line	:
City	:	SAINT ANTHONY
State	:	MN
Zip	:	55421-5052
Country	:	US
Telephone Number	:	763-781-7475
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2017
Last Update Date	:	06/07/2017

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